Louisiana Revised Statutes 22:2394 – Licensure as a utilization review organization
Terms Used In Louisiana Revised Statutes 22:2394
- Commissioner: means the commissioner of insurance. See Louisiana Revised Statutes 22:2392
- entity: means an individual, a corporation, a partnership, an association, a joint venture, a joint stock company, a trust, an unincorporated organization, any similar entity, or any combination of the foregoing. See Louisiana Revised Statutes 22:2392
- Health insurance issuer: means an entity subject to the insurance laws and regulations of this state, or subject to the jurisdiction of the commissioner, that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services, including through a health benefit plan as defined in this Section, and shall include a sickness and accident insurance company, a health maintenance organization, a preferred provider organization or any similar entity, or any other entity providing a plan of health insurance or health benefits. See Louisiana Revised Statutes 22:2392
- Independent review organization: means an entity that conducts independent external reviews of adverse determinations and final adverse determinations. See Louisiana Revised Statutes 22:2392
- person: includes a body of persons, whether incorporated or not. See Louisiana Revised Statutes 1:10
- Utilization review: means a set of formal techniques designed to monitor the use of or evaluate the clinical or medical necessity, appropriateness, efficacy, or efficiency of health care services, procedures, or settings. See Louisiana Revised Statutes 22:2392
- Utilization review organization: means a licensed entity that conducts utilization review in the internal claims and appeals process provided pursuant to La. See Louisiana Revised Statutes 22:2392
A. No health insurance issuer, or entity acting on behalf of, or agent of a health insurance issuer shall act as a utilization review organization unless authorized as such by the commissioner as provided in this Chapter.
B. Any other entity may apply for and be issued a license pursuant to this Chapter to act as a utilization review organization on behalf of a health insurance issuer.
C. An entity licensed as a utilization review organization shall notify the commissioner of any material change in fact or circumstance affecting its qualification for a license in this state within sixty days of the effective date of the change. The notice shall include any documentation that the commissioner may require. Changes in fact or circumstances shall include the following items:
(1) Changes in control as defined in La. Rev. Stat. 22:691.2.
(2) Amendments to the articles of incorporation.
(3) Changes in officers and directors.
(4) Merger or consolidation of the utilization or independent review organization with any other person or entity.
(5) Use of a trade name in this state.
Acts 2013, No. 326, §1, eff. Jan. 1, 2015.